Deparment of Anesthesiology and Pain Management, University of California, San Diego (UCSD) Medical Centre, San Diego, CA, USA.
Department of Anesthesiology, Helsinki University Central Hospital, Intensive Care, Emergency Medicine and Pain, Helsinki, Finland.
Rev Recent Clin Trials. 2023;18(3):228-237. doi: 10.2174/1574887118666230227113217.
Pituitary neurosurgery executed via the transsphenoidal endonasal approach is commonly performed for pituitary adenomas. Reasons for prolonged hospital stay include postoperative headache and protracted nausea with or without vomiting. Bilateral superficial trigeminal nerve blocks of the supra-orbital V1 and infra-orbital V2 (SION) nerves performed intra-operatively as a regional anesthetic adjunct to general anesthesia were hypothesized to decrease 6 hours postoperative morphine PCA (patient-controlled analgesia) use by patients.
Forty-nine patients, following induction of general anesthesia for their transsphenoidal surgery, were prospectively randomized in a double-blinded fashion to receive additional regional anesthesia as either a block (0.5% ropivacaine with epi 1:200,000) or placebo/sham (0.9% normal saline). The primary endpoint of the study was systemic morphine PCA opioid consumption by the two groups in the first 6-hours postoperatively. The secondary endpoints included (1) pain exposure experienced postoperatively, (2) incidence of postoperative nausea and vomiting, and (3) time to eligibility for PACU discharge.
Of the 49 patients that were enrolled, 3 patients were excluded due to protocol violations. Ultimately, there was no statistically significant difference between morphine PCA use in the 6 hours postoperatively between the block and placebo/sham groups. There was, however, a slight visual tendency in the block group for higher pain scores, morphine use p=0.046, and delayed PACU discharge. False discovery rate corrected comparisons at each time point and then revealed no statistically significant difference between the two groups. There were no differences between the two groups for secondary endpoints.
It was found that a 6-hour postoperative headache after endoscopic trans-sphenoidal pituitary surgery likely has a more complicated mechanism involving more than the superficial trigeminovascular system and perhaps is neuro-modulated by other brain nuclei.
经蝶窦内镜下经鼻入路进行的垂体神经外科手术常用于治疗垂体腺瘤。导致住院时间延长的原因包括术后头痛和持续时间较长的恶心，伴或不伴呕吐。双侧眶上神经 V1 和眶下神经 V2（SION）的浅表三叉神经阻滞术在全身麻醉下作为区域麻醉辅助用于手术中，假设可以减少术后 6 小时患者使用吗啡 PCA（患者自控镇痛）的次数。
49 例患者在全身麻醉诱导后接受前瞻性随机双盲分组，接受额外的区域麻醉，分为阻滞组（0.5%罗哌卡因加 1:200,000 肾上腺素）或安慰剂/假手术组（0.9%生理盐水）。该研究的主要终点是两组患者术后 6 小时内系统使用吗啡 PCA 阿片类药物的情况。次要终点包括（1）术后疼痛暴露情况，（2）术后恶心和呕吐的发生率，以及（3）有资格离开 PACU 的时间。
在纳入的 49 例患者中，有 3 例因违反方案而被排除。最终，阻滞组和安慰剂/假手术组在术后 6 小时内吗啡 PCA 使用量无统计学差异。然而，阻滞组的疼痛评分较高、吗啡使用率较高（p=0.046）和 PACU 延迟出院，存在略微的视觉倾向。每个时间点的错误发现率校正比较后，两组之间没有统计学差异。两组之间的次要终点没有差异。
内镜经蝶窦垂体手术后 6 小时的头痛可能具有更复杂的机制，涉及到不仅仅是浅表三叉血管系统，可能还受到其他脑核的神经调节。
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